When we think of medical malpractice, we think first of errors made by doctors – an incorrect test reading here, a nicked artery during surgery there. But according to Medscape, it is the way in which an electronic health record (EHR) is filled out that leads to errors.
The EHR has replaced the old-fashioned, hand-written chart, much as email has replaced the traditional hand-written letter. By keeping a patient’s records online, medical personnel have access to a complete history, and can easily send that history to other doctors, specialists, surgeons or therapists. But as with all online documentation, there are certain inherent risks – and those risks can negatively affect a patient when:
- The software fails. Doctors are still responsible for maintaining accurate records under the Health Insurance Portability and Accountability Act (HIPAA), but defective or infected software can have serious effects if the information is deleted or lost.
- Shortcuts are used. The article specifically mentions copying and pasting text, which makes it difficult for other doctors to find the information they need about their patients – information that could help a doctor avoid a misdiagnosis or a prescription error. The wrong text may be put into a file, and it shows a lack of engagement in a patient’s healthcare.
- There is open access to the computer. If a small office has one computer and everyone has access, the chances of hackers cutting into the system increases. Using a work computer to check social media or to download data from the internet can make it easy for viruses to infect the computer and affect the records.
- Doctors ignore the alerts. EHR software sets up a series of alerts called clinical decision support (CDS), which “remind” doctors to order certain tests, or to check for specific symptoms. Studies find that most doctors ignore or disable the feature, even though the alerts could help them make a correct diagnosis on a patient.
The article seems to imply that doctors treat the EHR system the same way people treat the “terms and agreements” button on websites. By choosing to use the system incorrectly, medical personnel put the health and lives of their patients at risk. The article describes the efforts as “sloppy,” and sloppy work could have devastating results. Patients have a right to expect a certain level of care from their doctors; treating patients’ EHRs as a nuisance lowers that level of care, and can lead to preventable errors.
For more information about medical malpractice and negligence, and to learn what Plaxen & Adler, P.A. can do to help, we invite you to visit plaxenadler.com.